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§ 142.5. Sequence of Proceedings to Resolve Benefit Disputes

(a) Usual sequence. Except as provided in this section, parties to a benefit dispute are required to attempt to resolve the dispute by mediation at a benefit review conference before proceeding to a contested case hearing or to arbitration by mutual election.

(b) Guidelines for proceeding directly to a benefit contested case hearing. Parties may proceed directly to a contested case hearing without attending a benefit review conference if the division determines that:

(1) mediation would not prove effective to resolve the dispute;

(2) necessary evidence cannot be obtained without subpoena; or

(3) the situation of the parties or the nature of the facts or law of the case is such that the overall policy of the Act would be advanced by proceeding directly to a contested case hearing.

(c) Requesting a hearing. A party may request that the division set a benefit contested case hearing. The request shall be made in the following manner:

(1) If the requester is a carrier, carrier representative, claimant represented by an attorney, or claimant assisted by OIEC, the request shall:

(A) be made in writing and signed by the requestor;

(B) identify and describe the disputed issue or issues;

(C) state the reason for requesting the hearing;

(D) be sent to the division; and

(E) be delivered to all the other parties, as provided by §142.4 of this chapter (relating to Delivery of Copies to All Parties).

(2) A claimant who is neither represented by an attorney nor assisted by OIEC may request a hearing by contacting the division in any manner.

(d) Division action on a request for hearing. The division will rule on the request and notify the parties. A ruling granting the request will include a notice of hearing, as provided in §142.6 of this chapter (relating to Setting a Benefit Contested Case Hearing). A ruling denying the request may include a notice of benefit review conference.

(e) Response. If a hearing is set upon request, the other party or parties may submit a response. The response shall:

(1) be made in writing and signed;

(2) describe and explain the party’s position on the dispute or disputes;

(3) be sent to the division no later than five days before the hearing; and

(4) be delivered to all other parties, as provided by §142.4 of this title (relating to Delivery of Copies to All Parties).

(f) A claimant who is neither represented by an attorney nor assisted by OIEC may respond by contacting the division in any manner.

The provisions of this §142.5 adopted to be effective February 12, 1991, 16 TexReg 463; amended to be effective May 10, 2000, 25 TexReg 3990; amended to be effective January 7, 2019, 44 TexReg 108.

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At a Glance:

Title:

§ 142.5. Sequence of Proceedings to Resolve Benefit Disputes

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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